DR. LOSAVIO’S RESEARCH FOCUSES ON EFFECTIVE THERAPIES FOR POSTTRAUMATIC STRESS DISORDER (PTSD) INCLUDING:
What makes them work? What are their key treatment ingredients that lead to symptom reduction?
Which work best for whom and under what conditions? Is it possible to match people to interventions to increase the likelihood of response?
How can we increase their reach? What training and implementation strategies increase the utilization of effective PTSD therapies by mental health providers?
SCHOLARLY RESEARCH
Research questions related to Interventions for PTSD
Select peer-reviewed journal articles authored or co-authored by Stefanie T. LoSavio, Ph.D, ABPP
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Many clinicians have concerns about delivering CPT, such as whether it will be effective for clients with comorbidities or childhood trauma and whether clients must first stabilize with preparatory treatments. In a review of key studies, CPT was shown to be effective and safe across a wide range of patients. CPT was effective for individuals with childhood trauma. Not only did individuals with comorbidities benefit on PTSD outcomes, but their comorbid symptoms often improved as well (e.g., depression, suicidal ideation, substance use, personality disorder symptoms). There was no evidence of benefit for delivering preparatory treatment before initiating CPT.
LoSavio, S. T., Holder, N., Wells, S. Y., & Resick, P. A. (in press). Clinician concerns about cognitive processing therapy: A review of the evidence. Cognitive and Behavioral Practice.
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WET has been shown to be efficacious for PTSD in clinical trials; however, it was unknown whether WET was effective in routine care settings, and whether any patient or treatment characteristics impacted outcomes. Examining data from a national implementation program in the Department of Veterans Affairs, WET was shown to have large effects on PTSD symptoms, and also moderate effects on depression and functioning. Patient outcomes did not differ regardless of whether the patients had comorbid depression or substance use issues, nor based on trauma type. WET was also effective when delivered in-person or via telehealth, and there was less dropout when delivered via telehealth. Overall, WET was effective across the patient and treatment characteristics examined and when delivered by professional therapists.
LoSavio, S. T., Worley, C. B., Aajmain, S. T., Rosen, C. S., Wiltsey Stirman, S., & Sloan, D. M. (2021). Effectiveness of written exposure therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System. Psychological Trauma: Theory, Research, Practice, and Policy.
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Examining a sample of active duty military personnel with PTSD receiving CPT as part of a clinical trial, those who were drinking heavily were no less likely to benefit from CPT, no more likely to drop out of treatment, and they benefitted with the same number of treatment sessions. Rates of drinking hazardously also decreased from 31% to 19% during CPT. This suggests those with PTSD who are also drinking heavily benefit from CPT, and effective trauma-focused treatment such as CPT should not be withheld.
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Examining data from a clinical trial of CPT for active duty military personnel, those who experienced childhood abuse were no less likely to complete or respond to treatment. This was true whether the service members received CPT in an individual or group format.
LoSavio, S. T., Hale, W. J., Moring, J. C., Blankenship, A. E., Dondanville, K. A., Schuster Wachen, J., Mintz, J., Peterson, A. L., Litz, B. T., Young-McCaughan, S., Yarvis, J. S., & Resick, P. A. (2021). Efficacy of individual and group cognitive processing therapy for military personnel with and without child abuse histories. Journal of Consulting and Clinical Psychology, 89, 476-482.
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This review highlighted that military personnel evidence significant symptom reduction during trauma-focused treatment for PTSD, although their outcomes are sometimes less pronounced than civilian populations.
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In this study comparing data from adolescent youth aged 14-17 to adults, there were no differences in PTSD and depression outcomes, and adolescents completed treatment in the same number of sessions without any specific modifications. Adolescents were more likely than adults to complete treatment.
LoSavio, S. T., Murphy, R. A. & Resick, P. A. (2021). Treatment outcomes of adolescents versus adults receiving cognitive processing therapy for posttraumatic stress disorder in the community. Journal of Traumatic Stress, 34, 757-763.
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Although it is very common to offer clients with PTSD preparatory treatment, such as skill-building or emotion regulation training, this study of military veterans receiving care in a Veterans Affairs clinic showed that only 24% of veterans who opted to receive preparatory group treatment subsequently engaged in trauma-focused treatment (CPT or PE). Those who did go on to trauma-focused treatment were no more likely to complete treatment than those who went into trauma-focused treatment directly and had less reduction in PTSD and depression symptoms. Other factors, such as avoidance, could explain why some patients chose preparatory treatment and had less response, but these data show no apparent benefit of trauma-focused treatment.
Dedert, E. A., LoSavio, S. T., Wells, S. Y., Steel, A. L., Reinhardt, K., Deming, C., Ruffin, R. A., Berlin, K. L., Kimbrel, N. A., Wilson, S. M., Boeding, S. E., & Clancy, C. P. (2021). Clinical effectiveness study of treatments to prepare for trauma-focused evidence-based psychotherapy at a Veterans Affairs specialty posttraumatic stress disorder clinic. Psychological Services, 18, 651-662.
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In a sample of active duty military personnel, a “variable-length” version of CPT was examined, where patients could end treatment early if they reduced their PTSD symptoms to a low level before 12 sessions, or receive additional sessions (up to 24 total) if they hadn’t yet reached a low symptom level by Session 12. Patients responded at various points in treatment, including before 12 sessions, in exactly 12 sessions, and after 12 sessions. Compared to a 12-session protocol of CPT, there were more participants classified as responders in the variable-length model.
Resick, P. A., Wachen, J. S., Dondanville, K. A., LoSavio, S. T., Young-McCaughan, S., Yarvis, J. S., Pruiksma, K. E., Blankenship, A., Jacoby, V., Peterson, A. L., & Mintz, J. for the STRONG STAR Consortium (2021). Variable-length cognitive processing therapy for posttraumatic stress disorder in active duty military: Outcomes and predictors. Behaviour Research and Therapy, 141, 103846.
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There have not been been consistent predictors of treatment outcome in CPT or other trauma-focused treatments. In a study examining a range of demographic, psychological, and military and deployment factors as predictors of treatment outcome among active duty military receiving CPT, the only significant variable to emerge was age, and it depended on whether treatment was delivered in an individual or group format. Younger participants had more symptom improvement than older participants, especially if they received individual treatment. That other variables did not predict outcome suggests that CPT is effective across a broad range of patient characteristics.
Resick, P. A., LoSavio, S. T., Wachen, J. S., Dillon, K. H., Nason, E. E., Dondanville, K. A., Young-McCaughan, S., Peterson, A. L., Yarvis, J. S., & Mintz, J. (2020). Predictors of treatment outcome in group or individual cognitive processing therapy for PTSD among active duty military. Cognitive Therapy and Research, 44, 611-620.
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Key theories suggest that changes in thinking, and especially reductions in self-blame during CPT, underlie symptom change. Looking at session-by-session data during CPT, it was observed that changes in self-blame did in fact precede and predict subsequent changes in PTSD symptoms; however, a reciprocal process was at play whereby changes in PTSD symptoms also predicted subsequent changes in self-blame. This supports targeting self-blame early in CPT and highlights how dynamic cognitive and other symptom changes are during treatment.
Dillon, K. H., Hale, W., LoSavio, S. T., Wachen, J. S., Pruiksma, K. E., Yarvis, J. S., Mintz, J., Litz, B. T., Peterson, A. L., & Resick, P. A. (2020). Weekly changes in blame and PTSD among active duty military receiving cognitive processing therapy. Behavior Therapy, 51, 386-400.
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Cognitive factors such as negative posttraumatic thoughts are a focus of theories about what underlies PTSD. This review highlighted research data further supporting the important role of cognitive factors in the development, maintenance, and treatment of PTSD, such as rumination, and points to cognitive change as a mechanism of evidence-based PTSD treatments.
LoSavio, S. T., Dillon, K. H., & Resick, P. A. (2017). Cognitive factors in the development, maintenance, and treatment of post-traumatic stress disorder. Current Opinion in Psychology, 14, 18-22.
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In a review of the literature on CPT delivered via telehealth, it was evident that CPT can be effectively delivered through this modality with good outcome, usually on par with effects from in-office treatment. Although other stressors may emerge, especially during current times and during the COVID-19 pandemic, these can be addressed as part of CPT while remaining trauma-focused.
Moring, J., C., Dondanville, K. A., Fina, B. A., Hassija, C., Chard, K. A., Monson, C., LoSavio, S. T., Wells, S. Y., Morland, L., A., Kaysen, D., Galovski, T. E., & Resick, P. A. (2020). Cognitive processing therapy for posttraumatic stress disorder via telehealth: Practical considerations during the COVID-19 pandemic. Journal of Traumatic Stress, 33, 371-379.
Research questions related to training and implementation
Select peer-reviewed journal articles authored or co-authored by Stefanie T. LoSavio, Ph.D., ABPP
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Learning Collaboratives are a more intensive type of training program than traditional workshop or workshop plus consultation models, in which clinicians participate as part of a team with involvement from a program administrator and implementation support is provided to help integrate the new practice into the clinical setting. In the first reported Learning Collaborative for CPT, there were strong outcomes observed at patient, provider, and organization levels. Clinicians evidenced good fidelity to the treatment, and patients evidenced large decreases in PTSD and depression symptoms. There was excellent sustainability over time, with 100% of agencies involved in the training continuing to offer the intervention 6 months post-training.
LoSavio, S. T., Dillon, K. H., Murphy, R. A., Goetz, K., Houston, F., & Resick, P.A. (2019). Using a Learning Collaborative model to disseminate cognitive processing therapy to community-based agencies. Behavior Therapy, 50, 36-49.
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Therapist stuck points are beliefs or concerns of therapists that may interfere with learning or delivering an evidence-based treatment. Therapist stuck points—particularly at the end of training or having less reduction in therapist stuck points during training—are associated with worse training outcomes including lower likelihood of completing training program requirements, less treatment fidelity, and less use of the treatment after training. However, therapist stuck points tend to decrease over the course of workshop training and clinical case consultation.
LoSavio, S. T., Dillon, K. H., Murphy, R. A., & Resick, P. A. (2019). Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training outcomes. Professional Psychology: Research and Practice, 50, 255-263.
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Examining data from a national Written Exposure Therapy (WET) training and implementation program, it was observed that, consistent with the Theory of Planned Behavior, clinicians were more likely to intend to deliver WET after training if they had more positive attitudes towards the intervention and perceived more control over whether they would deliver WET. Clinicians perceptions of WET became more positive over time, and the degree of change depended on how much reduction in PTSD symptoms their patients experienced (more symptom change in their patients was associated with developing more positive beliefs towards the intervention).
Worley, C. B., Rosen, C., LoSavio, S. T., Aajmain, S., Stirman, S. W., & Sloan, D. M. (in press). An examination of individual and organizational theory in a pilot virtual facilitated learning collaborative to implement written exposure therapy. Psychological Services.
Coming soon—in press!
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Examining outcomes of a fully virtual competency-based training and implementation program that occurred during the onset of the COVID-19 pandemic, the program, which involved a virtual live workshop, phone-based consultation, and video calls to support implementation efforts, was robust to the impacts of social distance guidelines and evidenced success in training 81% of participating clinicians.
Worley, C. B., LoSavio, S. T., Aajmain, S., Rosen, C., Stirman, S. W., & Sloan, D. M. (2020). Training during a pandemic: Successes, challenges, and practical guidance during a virtual facilitated learning collaborative for Written Exposure Therapy. Journal of Traumatic Stress, 33, 634-642.
for a full list of publications visit Google Scholar or Research Gate